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Medical error has been defined as an unintentional act (either of “omission” or “commission”) or one that does not achieve its intended outcome, the failure of a planned action to be finished as intended (an “error of execution”), using an incorrect plan to achieve a goal (an “errors of planning”), or a deviation from the method of care which could or might not cause harm to the patient.[1,2,3] Thus, a medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, behavior, infection, or other ailment. Medical errors include errors in diagnosis (”diagnostic errors”), errors in the administration of drugs and other medications (”medication errors”), errors in the performance of surgical procedures, in the use of other varieties of therapy, in the use of equipment, and the interpretation of laboratory findings.[1,2,3] It is critical to remember that a medical error occurs by an act performed in good faith; in contrast to medical malpractice, which is a damage or loss to a patient, as a result of the failure of a health practitioner to render proper services, either because of negligence, reprehensible lack of expertise, or even criminal intent.[1,2,3]
In the year 2000, the importance of identifying medical errors by medical institutions was highlighted by the U.S. Institute of Medicine (IOM) report “To Err is Human”; which said that greater than 1 million preventable errors in all likelihood occur every year within the U.S., and of these between 44,000 and 98,000 results in death.[4] This report had advocated that U.S. medical institutions need to initiate corrective steps to attain a 50% reduction in deaths due to medical errors over the following 5 years (by 2005).[4]
Following this worrying document, numerous Medical Error Reporting Systems (MERS) have been initiated within the developed world employing blended efforts made with the aid of governments, medical associations, and institutions to acquire more secure and higher quality patient care.[5] A few examples of these computer-handy, voluntary, and anonymous MERS designed for hospitals and health systems and accessible to health personnel include[5] the: (i) U.S. Pharmacopeia MEDMARX - a national medication error-reporting program, (ii) Centers for Disease Control's National Nosocomial Infection Survey, (iii) Medical Event Reporting System for Transfusion Medicine, (vi) the American Surgical Association's National Surgical Quality Improvement Program, (vii) Swiss Anesthesia Critical Incident Reporting System, (vii) Edinburgh Intensive Care Unit Critical Incident Reporting System, and (viii) Australian Incident Monitoring Study; that has led to documenting voluminous information on medical errors and numerous research publications highlighting the acute need for improved patient safety.[5,6] Nonetheless, Anderson and Abrahamson[7] have stated that healthcare professionals grossly underutilize MERS and less than 10% of medical errors are being reported. The common reasons for healthcare professionals not reporting effectively have been recognized as they being: (i) too busy in their routine and therefore too worn-out to report, (ii) unaware that they need to report, (iii) unaware how to do the reporting, (iv) wary of disciplinary or legal action or being perceived as being incompetent, (iv) demotivated by the lack of any immediate feedback and having the notion that the institution or system does not take visible corrective actions to prevent recurrence of the errors.[5,8,9] Schreiber et al.[6] have stated that 4079 related articles have been published in the period up to 2014 (most of them from the U.S., U.K., Canada, Germany, and Australia), highlighting that the access of knowledge and of safer technologies varies significantly in the different regions of the world.
Through the years research publications have highlighted that behavioral modifications in healthcare professionals (doctors, nurses, residents, pharmacists) are essential to make sure medical treatments are safer.[5,10,11,12,13,14,15] A few recent examples include the successful implementation of point-of-care ultrasound (”POCUS”) in decreasing diagnostic errors and reducing time to diagnosis in severely ill patients being evaluated in the emergency department.[10] Mohanty et al.[11] have analyzed the MEDMARX database to identify steps needed to prevent medication errors in patients receiving intravenous patient-controlled analgesia. It is widely recognized that patients are at risk of medication discrepancies all through transitions in care while getting admitted to the hospital, transferred to some other unit/intensive care unit, and while being discharged from the hospital. To thwart such errors the U.S.'s Institute for Healthcare Improvement (IHI) has formulated the idea of medication reconciliation for healthcare professionals.[16] Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking; which include drug name, dosage, frequency, and the route; and comparing that listing against the physician's admission, transfer, and/or discharge orders, to provide accurate medications to the patient at all transition points inside the hospital.[16] A recent systematic review by Manias et al.[12] has recognized a few single and combined interventions which can be effective in reducing medication errors in medical and surgical settings. This review has stated that: (i) prescribing errors were decreased through pharmacist-led medication reconciliation, computerized medication reconciliation, pharmacist partnership, prescriber education, medication reconciliation with the aid of skilled mentors, and computerized physician order entry (CPOE) as single interventions. CPOE systems are designed to replace a medical institution's paper-based ordering system and have the capability to be a powerful solution for limiting hospital medical errors.[17] They permit physicians to electronically write the overall range of orders, maintain an online medication administration record, and evaluate modifications made to order by successive health personnel.[17] Medication administration errors had been decreased with the aid of CPOE and the usage of an automated drug distribution system as single interventions. Combined interventions had been also discovered to be effective in reducing errors during prescribing or administrating medications. But no interventions had been observed to reduce dispensing error rates.[12] The World Health Organization Surgical Safety Checklist (WHO SSC), a simple, realistic tool that any surgical team in the world can use, is now recommended globally to prevent surgical site infection, ensure safer anesthesia, reduce mortality and also improve communication within the surgical team and with patients.[13,14,15]
Many hospitals with adequate resources have a comprehensive device of electronic medical records that can be analyzed to locate adverse drug events (ADEs); that are a major cause of morbidity and mortality worldwide. Medication errors are believed to be accountable for up to 20% of ADEs in patients during hospitalization.[18] In 2003, the IHI presented the Trigger Tool for measuring ADEs.[18] The tool identifies potential ADEs by well-defined clues present in patients' records, namely triggers. By using ADEs, pre-defined triggers are screened within the patients' chart until they are found. This procedure is followed by tracking the trigger retrospectively, a process that might reveal an ADE. This automated screening tool is getting used in many hospitals and contributing to reducing medication errors.[19] To enhance the quality and decrease the variations in care inside intensive care units (ICUs), the IHI has introduced the concept of care bundles.[20] Care bundles incorporate three to five evidence-informed practices, which need to be delivered collectively and continuously, to assist improve patient outcomes and decrease medical errors.[20,21] Lengthy working hours and heavy workloads are being increasingly recognized as factors that cause stress, chronic fatigue, and sooner or later burnout in physicians, residents, and nurses.[22,23,24] Burnout in these healthcare professionals is being recognized to result in suboptimal patient care practices and appreciably increase the risk of medical errors.[22,23,24]
Regrettably, even though two decades have passed since the IOM report, medical errors are still omnipresent; and deaths due to medical errors continue to be under-reported in almost all medical institutions and hospitals.?[7,25,26] Referring to the U.S., Makary and Daniel[26] have lately reiterated that over the last two decades the situation has in all likelihood worsened. Medical errors now probably account for as many as 251,000 deaths yearly (four times greater than the IOM estimate); that's 9.5% of all deaths in the U.S. and the third main cause of death after heart disease and cancer.[26] Wilson et al.[27] have reported that medical errors causing deaths may be more rampant in low- and middle-income countries. Makary and Daniel[26] have stated that medical errors are not included on death certificates or in rankings of cause of death because a major limitation of the death certificate is that it is based on assigning an International Classification of Disease (ICD) code to the cause of demise. As a result, causes of death not associated with an ICD code, which includes human and system factors, are not documented.[26] According to the WHO, 117 countries, including India, code their mortality data using the ICD system as the primary indicator of health status.[28] The current ICD-10 coding system has limited ability to capture most types of medical errors. At best, there are only some codes wherein the role of errors may be inferred, such as the code for anticoagulation inflicting adverse effects and the code for overdose events.[26] Makary and Daniel[26] have endorsed that when a medical error results in loss of life, both the physiological cause of the death and the associated problem with the delivery of care ought to be mentioned on death certificates. These factors raised by Makary and Daniel are well taken, but we must also take into account that attributing a death to medical error is a complex and challenging task that requires an analytical process with several implications. It is not always (maybe only in glaring cases) possible to attribute the cause of death to medical error immediately at the time of writing the death certificate.
To conclude, medical errors are an important public health global problem and pose a serious threat to patient safety and quality of care. Although medical errors are inevitable, decisive actions can be taken to noticeably lessen them and enhance patient safety. To attain this, an abiding culture dedicated to decreasing medical errors needs to be created at regional, national, and international levels. Because of the high-cost factor, many hospitals have been sluggish to invest in technologies, such as electronic medical records, MERS, CPOE systems, and care bundles that have helped lessen medical errors and enhance patient safety.[7] Government authorities ought to provide monetary incentives to medical institutions to invest in computerized technologies related to strengthening patient safety.[7] A “no blame” safety culture that would inspire ?healthcare professionals to actively report medical errors should be established in medical institutions.[6,29,30,31] Hospital management should provide well-timed feedback and implement visible corrective measures on an ongoing basis so that healthcare professionals continue to utilize these technologies optimally.[5,9] A wholesome healthy working environment along with the sagacious implementation of work-hour limitations would help prevent burnout in healthcare professionals.[32] Constant awareness, responsible attitude, and accountable professionalism by every member of the teamwork are key elements that contribute to reduce medical errors. Ensuring patient safety is not only a vital mission ahead but ought to be a commitment in a just healthcare system.
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